Medicaid Prior Authorization Request Form - Outpatient - Cigna

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MEDICAID
Prior Authorization Request Form – OUTPATIENT
Please fax to: 1-877-809-0790 (Home Health Services) or 1-877-809-0787 (All Other Requests)
Phone: 1-877-725-2688
(
* Required Field – please complete all required fields to avoid delay in processing
Note: In an effort to process your request in a timely manner, please submit any pertinent clinical information (i.e. progress notes,
treatment rendered, test/lab results or radiology reports) to support the request for services. Any request for a non-contracted provider
must include documentation to substantiate the reason for the request. (When all required information has been submitted we will
complete your request within 3 business days.)
Expedited Requests – defined as danger to a member’s health if not provided within 24 hours.
Phone: 1-877-725-2688
(
Then press prompt 3, for expedited prior authorization.
Member Information:
*Member Name:
*Member DOB:
/
/
* Member ID:
*Date of Service:
/
/
Requesting Provider Information:
*PCP/Requesting Provider:
Contact Person:
*Phone #:
*Fax #:
®
Referring to (servicing) provider information: if below fields are not answered, Cigna-HealthSpring
will
automatically assign Cigna-HealthSpring’s participating provider network to the member:
*Servicing Provider:
Contact Person:
Non-contracted
*Phone #:
Tax ID #:
NPI#:
*Fax #:
*Facility:
Contact Person:
Non-contracted
*Phone #:
Tax ID #:
NPI#:
*Fax #:
If requesting a non-contracted provider/facility, please explain why:
* Type of Service:
ASC
Elective Outpatient Surgery
Prosthetics/Orthotics
Please check only
MRI/MRA/CT PET
Office Procedure
Home Health
one of the boxes:
PT/OT/ST
Transplant Evaluation
Ambulance
DME
Cosmetic/Reconstructive
Other
Medication
Clinical Information:
*Diagnosis Code:
Diagnosis:
*Procedure/Service Requested:
CPT Code:
HCPCS Code:
Procedure/Service Description:
Number of visits:
Duration:
Frequency of visits:
Number of previous visits:
*Is supporting Clinical Information Attached?
Yes
No - Please summarize clinical information below
H8423_16_41182 02042016
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including HealthSpring Life &
Health Insurance Company, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. Cigna-HealthSpring
CarePlan is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees.

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